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Evidence to support a bidirectional relationship between diabetes andperiodontal disease has been emerging for more than 15 years. In 1993,Löe1 proposed that severe periodontitis was the sixth complication ofdiabetes; in 1996, Taylor and colleagues2 reported other compelling find-ings that severe periodontitis at baseline is associated with worseningglycemic control over time in a population-based study of Pima Indianswith diabetes who were noninsulin dependent.

Casey Hein, BSDH, MBA

Scottsdale Revisited:

The Role of Dental Practitioners in Screening for Undiagnosed Diabetes and the Medical Co-Management of

Patients with Diabetes or Those at Risk for Diabetes

In spite of the fact that these findings have been repro-duced and validated in countless studies reported during thepast decade, these important discoveries have yet to be trans-lated into everyday patient care in medical and dental prac-tices. In her exposé on the mysteries surrounding the rela-tionship between diabetes and periodontal disease, Lalla wasmore eloquent in her challenge to the healthcare professions:“We now have evidence that although growing understandingof the diabetes-oral link supports an increased primary andpreventive role for dentists in diabetes, this knowledge has nottranslated to real changes in clinical practice…There is clearlyroom for improvement in clinical practice, and looking ahead,research towards developing clinical support systems for den-tists [author (CH) suggests this should also include dentalhygienists, physicians, nurses, diabetes educators, dietitians]and also programs that facilitate the interaction and synergyamong all healthcare providers involved in the care of diabeticindividuals is of essence.”3 This kind of change may actuallybe underway. With a landmark report entitled the Report ofthe Independent Panel of Experts of ‘The Scottsdale Project’ (al-so known as The Scottsdale Report),4 the significance of oralhealth in promoting whole body health in individuals withdiabetes was brought to the forefront of the healthcare arena.

The intent of The Scottsdale Project, which convenedfrom April 11-13, 2007, was to bring together, for the firsttime, a wide range of medical and dental experts* to dia-logue about the quality of evidence related to the associationbetween diabetes, periodontal disease, and cardiovasculardisease. Furthermore, the independent panel of experts wastasked with defining whether the current data is meaning-ful and useful enough to justify the development of guide-lines for clinical decisions and patient management. Citingthe potential threat that periodontal disease may pose tosystemic health, specifically related to the increased risk forcomplications of diabetes, the experts discussed whethercurrent evidence is strong enough to support the adoptionof periodontal disease as a modifiable risk factor in decreas-ing the risk for diabetic complications and the developmentof heart disease and stroke.

The Scottsdale Report also spawned awareness of theimportance of medical-dental collaboration in the co-man-agement of patients who have increased risk for diabetes,or who have already been diagnosed with diabetes who alsomay have periodontal disease. In addition, the report pro-posed a transdisciplinary model of care that relies on bi-lateral point-of-care screening from medical and dentalproviders to identify and cross-refer patients who either areat risk for or who have undiagnosed periodontal disease, dia-betes, and cardiovascular disease (CVD) (ie, medical provid-ers screening for periodontal disease and dental providersscreening for diabetes and CVD).

There were two overarching, key issues that The ScottsdaleReport sought to address:

Key Issue I: Is it appropriate to develop guidelines thatassist dental providers in identifying patients who haveor who are at risk for diabetes and/or CVD, or screen-ing patients for undiagnosed diabetes and/or CVD whoneed to be referred to physicians?Key Issue II: Is it appropriate to develop guidelines thatassist medical providers in identifying patients whohave or who are at risk for periodontal disease, or screen-ing patients who may have undiagnosed periodontal dis-ease who need to be referred to dentists?

The Scottsdale Report reviewed evidence of the relation-ship between periodontal disease and CVD, and made spe-cific recommendations related to this area of investigation.This article discusses the report’s findings related to dia-betes and periodontal disease only. This article also ex-plores more current studies and literature reviews related tothis subject matter, selected for their relevance, includingliterature published after the consensus conference and notcontained in the body of evidence considered by panel ex-perts in their findings during the Scottsdale Conference.The article concludes by promoting the role of dentistsand dental hygienists in screening and co-management ofpatients with diabetes or those who are at risk for diabetes,and offers recommendations for how the findings of TheScottsdale Report and more recent research can be incorpo-rated into dental practice settings.

THE SCOTTSDALE CONCLUSIONSIn reference to Key Issue I, it was the consensus of thepanel of experts that it is appropriate to develop guide-lines to assist dental providers in identifying patients who

540 Compendium November | December 2008—Volume 29, Number 9

Scottsdale Revisited

*Charles Cobb, DDS, PhD; D. Walter Cohen, DDS; Möise Desvarieux, MD, PhD;

Sheila Garris, MD, FACP; Casey Hein, BSDH, MBA; Anthony Iacopino, DMD, PhD;

Evanthia Lalla, DDS, MS; Brian Mealey, DDS, MS; Lynnae Millar, MD;

Steven Offenbacher, DDS, PhD, MMSc; Robert Ostfeld, MD, MS;

David Paquette, DDS, MPH, DMSc; Shailesh Patel, BM, ChB, DPhil, FRCP;

Louis F. Rose, DDS, MD; Maria Ryan, DDS, PhD; Souvik Sen, MD, MS, FAHA;

Maurizio Trevisan, MD, MS; Karen Williams, RDH, PhD



are at risk for diabetes. The experts concluded that a thor-ough search for patient-provided information that maylead to a diagnosis to improve oral and systemic healthshould be conducted by dental providers. The panel rec-ommended the following protocols for dental providers toscreen patients for diabetes:

1. Patients at risk for diabetes (information obtained fromthorough family and personal medical history), regard-less of oral presentation, should be referred by dentiststo laboratories to have their fasting blood glucose lev-els checked and/or referred to their physician for fur-ther diagnostic evaluation.

2. Patients with severe periodontitis (severe for age, fail-ure to respond to treatment, abscesses) or fungal infec-tion should be considered for referral to their physicianfor screening for diabetes.

3. If laboratory testing for diabetes is performed in a dentalcare setting, it should be done in accordance with Amer-ican Diabetes Association screening guidelines (fastingblood glucose) with appropriate follow-up of laboratorydata and communication with the physician.

4. For the patient who has been diagnosed with diabetes(and/or CVD), dentists should work collaborativelywith physicians to achieve the best possible patientcare outcomes. A set of guidelines should be developedto define what is important for bidirectional interpro-fessional communication.

5. Patients already diagnosed with diabetes who do nothave a treating physician are at high risk for cardiovas-cular events and should be seen by a physician.

In reference to Key Issue II, the panel of experts deter-mined that it is appropriate to develop guidelines thatassist medical providers in identifying patients who are atrisk for periodontal disease or screening patients whomay have undiagnosed periodontal disease who need to bereferred to dentists. Furthermore, they noted, medicalproviders’ recognition of the signs and symptoms associat-ed with periodontal disease may identify patients who areeither at risk or who are undiagnosed who should be re-ferred to the dental provider. They concluded that physi-cians can screen for signs and symptoms associated withperiodontal disease based on patient history, symptoms,and a visual assessment of the patient’s teeth and gums.

Accordingly, the expert panel of The Scottsdale Pro-ject recommended that medical providers screen and refer

all patients suspected of having periodontal disease, aswell as the following management plan for patients withdiabetes.

1. Patients with diabetes should be managed medically asrecommended by the American Diabetes Association.

2. Patients with diabetes should have a dental examina-tion at a minimum of twice a year, or more frequentlyif advised by the dental provider, and receive appropri-ate dental/periodontal care.

3. There should be close communication between theprimary care physician and the dentist.

4. Medical providers should advise the patient with peri-odontal disease that this is a chronic infection of thegums and an important complication of diabetes.

5. Medical providers also should advise patients that peri-odontal disease has been associated with significanthealth problems, including worsening metabolic con-trol and other complications of diabetes, coronary ar-tery disease, and stroke.

6. Medical providers should advise the patient that peri-odontal disease can be treated by the dentist and den-tal hygienist.

7. If the patient has not seen a dentist within the last yearor if there are signs of periodontal disease, the patientshould be advised to make an appointment to see a den-tal provider right away.

It is important to note that the expert panel’s recommen-dations for clinical guidelines should not be interpreted tomean that the scientific evidence is fully adequate. In formu-lating its recommendations, the expert panel assessed onlythe evidence available at the time of the consensus meeting.

THE NEXT CHAPTERS: ADDRESSING THE UNKNOWNSAlthough much has been achieved in the investigation of therelationship between diabetes and periodontal disease, thereare still many unanswered questions including the following:

1. What exactly are the biologic mechanisms involved inthe pathogenesis of periodontal disease in individualswith diabetes?

2. Does periodontal disease have an effect on glycemiccontrol and increase the risk for complications of dia-betes? Does treatment of periodontal disease affect adecrease in insulin requirements of patients with poor-ly controlled diabetes?

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3. For children and adolescents with diabetes, what is theirincreased risk for oral diseases?

4. What are the inflammatory pathways that link obesity,metabolic syndrome (MetS), and periodontal diseases?

MORE RECENT VALIDATION OF THE DIABETES-PERIODONTALDISEASE RELATIONSHIPA number of articles published since the consensus proceed-ings of The Scottsdale Project are noteworthy. The findingsof various studies underscore the importance of increasingawareness of the bidirectional relationship of diabetes andperiodontal diseases within the medical community.

In a 2008 review of evidence published since year 2000,Taylor and Borgnakke5 validated previously reported con-clusions that diabetes is associated with increased occur-rence and progression of periodontitis and, further, thatperiodontal infection is associated with poorer glycemiccontrol in individuals with diabetes. The authors reviewed17 cross-sectional studies and concluded that the adverseeffect of diabetes on the periodontium are consistent withthe meta-analyses conducted by Papapanou, published in1996,6 and Khader and colleagues, published in 2006.7

In addition, this literature review provided supplemen-tal evidence to suggest a dose response relationship betweendiabetes and periodontal diseases. More specifically, asglycemic control deteriorates, the negative effect of diabeteson the health of the periodontium appears to be enhanced.5

In examining the evidence related to the effect of the de-gree of glycemic control on periodontal status, the authorsreviewed 11 cross-sectional studies and one prospectivestudy. In examining the evidence related to the effects ofperiodontal disease and its treatment on glycemic control,the authors reviewed 22 publications with various studydesigns. They concluded that the evidence under reviewsuggested that infection from periodontal origin may con-tribute to poorer glycemic control and the risk of diabeticcomplications. The authors further proposed that thesefindings must be validated by rigorous, controlled trials indiverse populations.5

NEW FINDINGS ON THE DENTAL CARE OF ADOLESCENTS AND CHILDREN WITH DIABETESMore recently, Lalla and colleagues8 reported findingsfrom a number of studies related to the increased risk of

oral complications in childhood and adolescent diabetes.In one study, which examined the periodontal integrity of350 children with diabetes and 350 nondiabetic controlsbetween 6 and 18 years of age, the investigators found thatyoung subjects with diabetes had a statistically significantincrease in gingival inflammation (mean gingival index =1.14 vs 1.08, respectively, unadjusted P = .006; the percent-age of sites that bled on examination was 19% vs 13.6%,respectively, unadjusted P < .001). Attachment loss, cal-culated as the percentage of sites > 2 mm, was also sig-nificantly higher in subjects with diabetes compared tonondiabetic controls. When the subgroups, 6 to 11 yearsof age and 12 to 18 years of age, were analyzed separately,the negative effect diabetes had on the integrity of the peri-odontium remained significant. These findings led theresearchers to conclude that there is an association betweendiabetes and an increased risk for periodontal destructionand that this relationship may be initiated very early in thelives of children and adolescents with diabetes. It was con-cluded that diabetes, as an important risk factor for peri-odontitis, may have greater significance sooner in life thanpreviously recognized by earlier research.9,10

In a parallel study, Lalla and colleagues11 investigateddiabetes-related parameters that might be associated withthe accelerated destruction of the periodontium duringchildhood and adolescence. Periodontal examinations wereperformed on 350 6- to 18-year-old subjects with dia-betes, and data on important diabetes-related variables(ie, type and duration of diabetes, age at diagnosis, modeof insulin therapy, mean glycated hemoglobin [Hb A1c]over the past 2 years, body mass index [BMI]) were collect-ed. Of these subjects, 93% had type 1 diabetes and weretreated with insulin only. The case definition used to de-fine periodontitis included both gingival bleeding andattachment loss. After adjusting for several relevant vari-ables, investigators found a strong positive association be-tween mean Hb A1c (a measure of the cumulative bloodsugar level over the patient’s recent history, usually about3 months; correlates with risk for diabetic complications)and periodontitis (odds ratio = 1.31, P = .030). Within thewhole study population, Hb A1c significantly correlatedwith gingival bleeding; however, attachment loss alone wasnot correlated significantly. The researchers concluded thatthese findings provide evidence that in young individualswith diabetes, changes in the microvasculature of the peri-odontium may be related to metabolic control. To that end,



Lalla and colleagues11 proposed that good glycemic con-trol is essential in the prevention of periodontal complica-tions in young patients with diabetes.

In studies conducted over the past 35 years, there areconflicting reports of how diabetes may influence patternsof tooth eruption in children. In the largest cohort study todate (ie, 270 children with diabetes and 320 children withoutdiabetes) Lal and colleagues12 found that children withdiabetes, aged 10 to 14 years (late mixed dentition stage)

had a higher propensity for advanced tooth eruption thanthe control group without diabetes. The authors appropri-ately noted that this stage of dental development corre-sponds with puberty and growth spurts, and consequently,adolescents with diabetes may be at greater risk for acceler-ated dental development as a result of the systemic effectsof diabetes. As further noted by the authors, many orofacialcomplications, such as malocclusion, crowding, impairedoral hygiene, periodontal disease, and the need for ortho-dontic correction, are correlated with disturbances in thetiming or sequence of tooth eruption.12

EMERGING EVIDENCE ON THEINTERRELATIONSHIP BETWEEN OBESITY, METABOLIC SYNDROME, AND PERIODONTAL DISEASEIn a recent survey of the literature, Pischon and colleagues13

reviewed mounting evidence that suggests that obesity isassociated with oral diseases, particularly periodontal dis-ease. The authors noted that although the underlying bio-logic mechanisms between obesity and periodontal diseasehave yet to be established, what is conclusive is the role ofadipose tissue in actively secreting a variety of cytokines andhormones that are recognized etiologically in the inflamma-tory process. The authors theorized that similar pathwaysare involved in the pathophysiology of obesity, periodonti-tis, and related inflammatory diseases. Also cited is evidenceto support that obesity is second only to smoking as thestrongest risk factor for inflammatory periodontal tissuedestruction.13 Obesity, now considered a systemic disease,is a known risk factor for several chronic diseases such ashypertension, type 2 diabetes, dyslipidemia, and coronaryheart disease (CHD) and as such should be recognized as amultiple-risk-factor syndrome for overall and oral health.Pischon and colleagues put forward a model that links peri-odontitis and obesity with inflammatory related chronicdisease states (Figure 1).

The authors also proposed that given the prevalence ofobesity (more than 60% of the US population is over-weight or obese), treating overweight individuals in thedental care setting will become the norm. Furthermore,the authors suggested that measurement of BMI and waistcircumference as part of periodontal risk assessment shouldbe performed on a routine basis.13

In describing the role of obesity and insulin resistanceas a biologic mechanism common to both periodontal

Figure 1 Model proposed by Pischon and colleagues to

explain the relationship between periodontitis, obesity, and

inflammatory driven disease states. (Reprinted with permis-

sion from the Journal of Dental Research: Pischon N et al.13)

Figure 2 Theorized model to describe the biologic plausibility

of the interrelationships of obesity, insulin resistance, peri-

odontal disease, and systemic diseases such as diabetes and

heart disease. (Reprinted with permission from Curr Opin

Endocrinol Diabetes Obes: Mealey BL, Rose LF.14)

Obesity TNF-α

Liver

Insulin hCRP resistance

Hyperinsulinemia Hyperlipidemia Hyperglycemia (hCH, hTG)

Type 2 diabetes Heart disease

Periodontal disease

Obesity, Periodontal Disease,Type 2 Diabetes, and Cardiovascular Disease

Environmental Factorseg, smoking, nutrition,

physical activityGenetic Factors

Periodontitis(Bacterial factors)

ObesityAdipose tissue

Elevated synthesis of inflammatory cytokines(TNF-a, IL-1, IL-6…)

Chronic diseases(Type 2 diabetes, CHD…)

infection and systemic complications, such as type 2 dia-betes and CVD, Mealey and Rose14 offered another modelto explain the biologic plausibility of these interrelation-ships (Figure 2).

Engebretson and colleagues15 recently reported a study of46 patients with type 2 diabetes and chronic periodontitis de-signed to determine to what extent periodontitis influencescirculating tumor necrosis factor-alpha (TNF-a) levels insubjects with diabetes. TNF-a is a cytokine known to playan important role in mediating the insulin resistance ofobesity through its overexpression in fat tissue.16 The in-vestigators hypothesized that periodontal infection andinflammation influence TNF-a levels in the circulation ofpatients with diabetes, playing an important role in insulinresistance. Findings included a significant positive correla-tion between TNF-a and attachment loss, plasma endo-toxin, and gingival crevicular fluid levels of interleukin-1beta (IL-1b), but not probing depth, bleeding on probing,plaque index, serum glucose, Hb A1c. A dose response rela-tionship between the severity of periodontitis and TNF-awas observed. Engebretson and colleagues concluded thatchronic periodontitis may influence levels of circulatingTNF-a in individuals with diabetes and periodontal infec-tion, and inflammation may contribute to insulin resistance.

Recently, there have been a number of papers written insupport of more active involvement of dental practitionersin the identification and treatment of obesity-related con-ditions. One of these conditions, the MetS, is characterizedby obesity, dyslipidemia, insulin resistance, high blood pres-sure, and a proinflammatory and prothrombotic state.17

Friedlander and colleagues18 published a recent litera-ture review pertaining to the dental implications of MetS.The authors concluded that “given the prevalence andadverse cardiovascular outcomes of MetS, dentists [author(CH) suggests this should extend to dental hygienists also]need to consider MetS when formulating risk assessmentsfor middle-aged and older patients…” In their literaturereview, Friedlander and colleagues also emphasized theimportance of developing treatment plans that preserve thenatural dentition, thereby providing for optimal mastica-tory efficiency and the greatest potential to ensure thatpatients at risk for MetS are able to eat foods that do notcontribute to atherogenesis (ie, fruits and vegetables).

Conducted by Nibali and colleagues,19 another studyinvestigated whether periodontitis, as a chronic infectionwith low-grade systemic inflammatory properties, might

represent one of the etiologic factors contributing to MetSand subsequently increased risk for diabetes and CHD.Subjects (302 patients with severe periodontitis and 183healthy controls) were examined periodontally and bloodsamples were obtained to ascertain levels of inflammatoryand metabolic factors in healthy and periodontitis pa-tients. The authors concluded that within the limitationsof a case-control design, their findings suggested thatpatients with untreated severe periodontitis may be predis-posed to increased risk of MetS and, therefore, CVDs.These findings provided further evidence of the interrela-tionships of inflammatory driven disease states and make acompelling case for the cumulative burden of inflamma-tion associated with multiple-risk-factor disease states.

AGGRESSIVE MANAGEMENT OFPERIODONTAL DISEASE AND ITSPOTENTIAL TO REDUCECOMPLICATIONS OF DIABETESLifestyle interventions, such as modification of diet andexercise, are the first line of defense in preventing and man-aging diabetes.20 Clearly there is a role for dentists and den-tal hygienists in these types of interventions and monitor-ing patient outcomes in the care of patients with diabetes,those who are at risk for diabetes, or those who were diag-nosed with prediabetes. Glycemic control and blood pressureand cholesterol management affect a reduction in microvas-cular and macrovascular complications of diabetes and sub-sequently decrease the risk for cardiovascular events.20 So“tight control” of blood glucose levels has become the keyto reducing the risk of diabetic complications. In a 2008review on the prevention and treatment of diabetes and itsassociation with oral diseases, Skamagas and colleagues20

discussed the contribution of severe periodontal disease tosystemic inflammation and its potential to increase insulinresistance. The authors proposed that aggressive manage-ment of periodontal disease in diabetes case managementhas the potential to reduce the “inflammatory milieu’s”detrimental effects on diabetes control and subsequentlydecrease the risk for a cardiovascular event.

In her comprehensive paper on “Diagnostic and Ther-apeutic Strategies and the Management of the Diabetic Pa-tient,” Ryan discussed the importance of periodontal healthfor people with diabetes.21 The author cited a well recog-nized clinical trial, The Diabetes Control and Complica-tions Trial (DCCT),22 which offered compelling evidence



that improved control of blood glucose reduces the risk ofa number of long-term complications of diabetes, espe-cially retinopathy, nephropathy, and neuropathy. As aresult of these findings, the major objective of diabetesmanagement is to reduce and then maintain low Hb A1clevels (4% to 6%). Ryan described the sequelae of untreat-ed periodontal disease as a chronic inflammatory statethat leads to increased insulin resistance, reduced glucosetolerance, and increased risk of diabetic complications.Three studies23-25 cited by Ryan demonstrated that dia-betic subjects with severe periodontitis are at greater riskfor developing nephropathy and CVD. In her conclusion,Ryan put forth this cascade of etiological events: “Poorlycontrolled diabetes increases the risk for periodontitis;periodontal infection and treatment of periodontal diseasecan alter glycemic control; and further, early interventionand treatment of periodontitis may help to prevent thelong-term complications of diabetes, such as nephropathyand cardiovascular disease, thereby having an impact onmortality.”21

Other investigators are exploring how the inflammatorystate of periodontal disease may contribute to accelerationof CVD, the No. 1 cause of death from diabetes. More re-cently, Lalla and colleagues published a small pilot study26

that explored the effects of anti-infective periodontal treat-ment in patients with diabetes and whether this therapeuticintervention influenced alterations in the proinflammatorypotential of peripheral blood mononuclear cells. These pro-inflammatory components are known to contribute to thedevelopment and/or progression of atherosclerosis-relateddiseases. The study included 10 subjects with diabetes andmoderate to severe periodontitis who received full-mouthsubgingival debridement, and in whom blood samples weredrawn to observe changes in levels of various serum markersbefore treatment and 4 weeks after therapy. Findings, 4 weeksafter treatment, included:

n Clinically and statistically significant improvements inperiodontal parameters (ie, percentage of sites that bled onprobing, the number and percentage of pockets ≥ 5 mm,the number and percentage of sites with attachment lossof ≥ 5 mm)

n Only a modest reduction in the levels of subgingival bac-teria and a marginal effect in serum immunoglobulin Gtiters to periodontal bacteria

n Significant suppression of serum C-reactive protein andsE-selectin, but no change in plasma fibrinogen

n Percentage of mononuclear cells with proinflammatoryproperties significantly decreasedThese findings led the researchers to conclude that

macrophages, derived from peripheral blood, have thecapability to produce TNF-a in diabetes-associated peri-odontitis, and furthermore, periodontal therapy may effecta reduction in the production of TNF-a and the numberof circulating monocytes. As noted by the authors, furtherstudies with a larger cohort are required to fully under-stand this relationship; however, the finding that peri-odontal therapy may have an effect on the production ofTNF-a has important implications in addressing theinflammatory complications of diabetes, specifically ather-osclerosis, in which TNF-a may play a role in pathogenesis.

Recent research by Lim and colleagues27 provided furtherevidence of the importance of “tight” glycemic control inensuring periodontal health in people with diabetes. Thestudy was comprised of 181 adult patients with either type 1or type 2 diabetes. Other inclusion criteria included at least8 natural teeth and no known major medical complications.Subjects received full-mouth periodontal assessment, whichincluded the presence of bleeding on probing (BOP) andprobing depth measurements. Smoking status was recorded.Blood samples were collected on all subjects and analyzedfor markers of metabolic control and inflammation includ-ing Hb A1c, high sensitivity C-reactive protein (hsCRP) andlipid profile (ie, triglycerides, low-density lipoprotein [LDL],and high-density lipoprotein [ HDL]). In this study popula-tion Hb A1c emerged as the single significant predictor ofBOP (P = .05), and both Hb A1c and hsCRP emerged as si-gnificant predictors of percentage of probing depths ≥ 5 mm(P = .05). As a marker of metabolic control of diabetes, HbA1c was correlated positively with LDL, triglycerides, andtotal cholesterol. The finding that there is a correlation be-tween glycemic control and the severity of periodontal dis-ease concurred with previous studies.2,28 The authors con-cluded that this study confirmed that poor glycemic controlis the most significant risk factor associated with periodontalstatus; furthermore, that these findings underscore the im-portance of promoting oral health as a component of totalpatient care in patients with diabetes.

THE ROLE OF DENTAL PRACTITIONERSIN SCREENING AND CO-MANAGEMENT Evidence suggests that dental providers may not recognizeor embrace a role in screening for undiagnosed diabetes


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and in the co-management of patients with diabetes orthose at risk for diabetes. A survey of general dentists pub-lished in 2006 indicated that only 7% of respondentsscreen for diabetes, and only 26% take an active role in themanagement of patients with diabetes.29

The pandemic of diabetes demands that the responsi-bility for screening and co-management be incorporatedthroughout healthcare, including all point-of-care pro-viders, such as dentists and dental hygienists. With eachnew year, statistics on the prevalence of diabetes are revisedupward; there seems no end in sight to this mounting pan-demic. Today there are 23.6 million people in the UnitedStates, or 8% of the population, who have diabetes. Thisincludes 17.9 million people who have been diagnosed andanother 5.7 million who are undiagnosed.30,31 The totalprevalence of diabetes increased 13.5% from 2005 to 2007.It is estimated that 57 million people have prediabetes.30,31

Future projections of diabetes are even more dismal. Figure 3provides projections of the future prevalence of diabetesthrough year 2050.32 It is important to note that the currentprevalence of diabetes in the United States is 8%, which al-ready has exceeded previous forecasts of 6.8% in year 2010.

Given the frequency of patients’ visits to the dental of-fice (more than 60% of Americans visit the dental office atleast once a year and most of the visits are for routine, non-emergent care33), dentists and dental hygienists are uniquelypositioned to intercept undiagnosed diabetes. In a gener-al dental practice with 2,000 adult patients, statistically it

is reasonable to assume that about 40 patients will havediabetes which has not been diagnosed. Borrell and col-leagues34 developed a predictive model that would assistdental providers in identifying undiagnosed diabetes intheir patient base by using self-reported data commonlyqueried in a medical history questionnaire and data recordedin periodontal examinations, both of which are routinelyconducted in dental practice settings.

Analysis34 of data from the Third National Health andNutrition Examination Survey (NHANES III) and peri-odontal examinations provided compelling evidence thatsubjects with a self-reported family history of diabetes, hy-pertension, and high cholesterol, along with clinical evi-dence of periodontal disease (defined as at least 2 sites withclinical attachment level of ≥ 6 mm and at least one site witha pocket depth of ≥ 5 mm) had a 27% to 53% probability ofhaving undiagnosed diabetes. Mexican-American men hadthe highest probability and white women the lowest proba-bility. The researchers34 also found that as the presence ofreported risk factors (for diabetes) increased, the probabilityof having undiagnosed diabetes increased, conveying a syn-ergistic effect of a relatively small number of risk factors.The authors concluded by appropriately noting that dentalproviders’ screening for undiagnosed diabetes carries with itthe responsibility for medical follow-up in terms of referralfor blood glucose testing to establish a diagnosis.

Given their professional calling, dentists and dental hygien-ists are also well positioned to promote important lifestyle



Figure 3 Projections of future prevalence of diabetes within the United States. (Adapted from: Narayan KM, Boyle, JP, Geiss LS, et al.32)

Projections of Epidemic Trends in Diabetes

2005 2010 2020 2030 2040 2050

Prevalence 5.6% 6.8% 8.9% 10.4% 11.4% 12%(All Ages)

Forecast of number ofindividuals diagnosed 16.2 20.5 28.8 36.4 42.8 48.3

with diabetes (US)(in millions)

modifications for patients at risk for diabetes, and collabo-rate with physicians, nurses, diabetes educators, and dieti-tians (among others) in progressive co-management of pa-tients with diabetes. In the same scenario of 2,000 adultpatient base, it is reasonable to expect that about 160 pa-tients have been diagnosed with diabetes, many of whomwill require progressive case management for their oral healthand collaborative interventions with other healthcare pro-viders to ensure optimal metabolic control of diabetes andreduced risk or delay of complications of diabetes. Ac-cordingly, “physicians should expect increased interactionwith oral health professionals in the future, as evidence con-tinues to accumulate that inflammatory periodontal diseasesand diabetes are closely linked together.”14

The American Diabetes Association has made somerather bold statements,35 which call into question the abilityof the current healthcare delivery system to implementthese standards of care for diabetes. Some of these state-ments follow.

n The implementation of the standards of care for diabeteshas been suboptimal in most clinical settings.

n A major contributor to suboptimal care is a deliverysystem that too often is fragmented, lacks clinical in-formation capabilities, often duplicates services, and ispoorly designed for the delivery of chronic care.

Indeed, dentistry and dental hygiene have the opportu-nity to become part of a greater solution to challenges as-sociated with the implementation of standards of care fordiabetes and to remedy a delivery system that is fragmentedand not able to address the chronic nature of diabetes.

CLINICAL IMPLICATIONS TO THE PRACTICEOF DENTISTRY AND DENTAL HYGIENEDental practitioners are well positioned to actualize therecommendations embodied within The Scottsdale Reportand incorporate into everyday practice the findings of rele-vant research on the inflammatory driven interrelation-ships of diabetes, obesity, and periodontal disease thatcontinue to emerge. Listed are a number of suggestions forimplementation.

1. Screen adult, adolescent, and child patients for un-diagnosed diabetes. Criteria for referring individu-als for blood glucose testing to establish a diagnosis ofdiabetes are listed in Table 1 and Table 2.36 These guide-lines are updated by the American Diabetes Association

on an annual basis and published in Diabetes Care atthe beginning of each year.

2. Counsel patients with diabetes about the possible peri-oral complications of diabetes, including gingivitis,periodontitis, xerostomia, candidiasis, oral lichenplanus, leukoplakia, and oral cancer.20 Various stud-ies37 have found that the majority of individuals withdiabetes are unaware of the link between diabetesand periodontal disease and that in comparison withtheir knowledge of other complications of diabetes,their knowledge of increased risk for periodontal dis-ease is low.38

3. Counsel patients with diabetes about the potentialeffect of periodontitis on glycemic control. The pres-ence of periodontitis increases the risk of worseningglycemic control (perhaps six-fold increased risk ofworsening glycemic control over time).39 Some studiesshow that diabetic patients with periodontitis require


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Table 1:Criteria for Testing for Prediabetes and Diabetes in Asymptomatic Adult Individuals36

1. Testing should be considered in all adults who are over-weight (BMI = 25 kg/m2) and have additional risk factors:

n Physical inactivityn First-degree relative with diabetesn Member of a high-risk ethnic population (eg, African

American, Latino, Native American, Asian American,and Pacific Islander)

n Delivered a baby weighing 9 lb or were diagnosed with gestational diabetes mellitus (GDM)

n Hypertension (140/90 mm Hg or on therapy forhypertension)

n HDL cholesterol level 35 mg/dL (0.90 mmol/L) and/or a triglyceride level 250 mg/dL (2.82 mmol/L)

n Polycystic ovarian syndrome (PCOS)n Impaired glucose tolerance or impaired fasting glucose

on previous testingn Other clinical conditions associated with insulin resist-

ance (eg, severe obesity and acanthosis nigricans)n History of CVD

2. In the absence of the above criteria, testing for predia-betes and diabetes should begin at 45 years of age.

n If results are normal, testing should be repeated at leastat 3-year intervals, with consideration of more frequenttesting depending on initial results and risk status.

less insulin after treatment for periodontal disease.39

Studies that have measured the difference in Hb A1cafter treatment for periodontal disease reported im-provements in Hb A1c ranging from 0 to 2 percentagepoints in Hb A1c levels; however, studies are inconclu-sive.39 Patients with poorer glycemic control may havemore rapid recurrence of deep pockets and less favor-able long-term response to treatment.39

4. For children and adolescents who are diagnosed withdiabetes or those who are at risk for diabetes, carefullyscreen for accelerated tooth eruption, caries, and in-flammation of soft tissues. In these patients (Table 2),36

early identification of individuals susceptible to peri-odontal diseases and/or caries may allow for more aggres-sive therapies, more frequent care, and interventions thatcould help prevent or minimize the destruction of hardand soft tissues of the oral cavity later in life. In theirchallenge to healthcare providers, Lalla and colleagueswrote, “In consideration of the present findings [thebidirectional relationship between diabetes and peri-odontal disease], oral screenings and periodontal preven-tion/treatment programs should be considered as a stan-dard of care for young patients with diabetes.”8

5. Help educate other healthcare providers in the impor-tance of oral screening of young patients with diabetes.Collaboration with other healthcare providers is key inproviding optimal care for both oral and systemichealth in patients with diabetes. The American Dia-betes Association recommends an oral examination asone of the components of the initial visit of childrenand adolescents with diabetes.40 However, helpingnondental care providers understand the significanceof the bidirectional relationship between diabetes andperiodontal disease may promote the provision for oralscreenings in young people with diabetes as a standardof continuing care visits, beyond the initial visit fornewly diagnosed children and adolescents. Programsto address periodontal needs should be the standard ofcare for diabetic youth.8 Kapp and colleagues41 ob-served that people with diabetes may be 1.46 times aslikely (95% confidence interval [CI], 1.30 to 1.64) tohave at least one tooth removed than nondiabetic indi-viduals are, and that the association between diabetesand tooth loss was stronger among younger subjects(aged 18 to 44 years). These findings led the re-searchers to conclude that, “multidisciplinary effortsare needed to raise awareness of the risk of tooth lossamong younger people with diabetes.”41

6. Monitor clinical outcomes of periodontal treatmentand the glycemic control of patients. This includesroutine periodontal examinations that are comprehen-sive (including evaluation and recording of BOP, pock-et depth, recession, attachment loss, plaque index,inflammation) in addition to requesting patients’ labo-ratory records of Hb A1c.42 “Given the potential linkbetween periodontal disease, diabetes, and cardiovas-cular disease, aggressive management of oral healthand regular follow-up seems a reasonable approach.”20



Table 2:Criteria for Testing for Type 2 Diabetes in Asymptomatic Children36

Overweight (BMI = 85th percentile for age and sex, weightfor height 85th percentile, or weight 120% of ideal forheight). Plus any two of the following risk factors:

n Family history of type 2 diabetes in first or second-degreerelative

n Race/ethnicity (eg, Native American, African American,Latino, Asian American, and Pacific Islander)

n Signs of insulin resistance or conditions associated withinsulin resistance (eg, acanthosis nigricans, hypertension,dyslipidemia, or PCOS)

n Maternal history of diabetes or GDM

Age of initiation: 10 years or at onset of puberty, if pubertyoccurs at a younger age

Frequency: every 2 years

Test: fasting plasma glucose preferred

Table 3: Criteria for the Definition of Metabolic Syndrome44

Individuals having three or more of the following criteriawere defined as having the metabolic syndrome:

n Abdominal obesity: waist circumference > 102 cm in menand > 88 cm in women

n Hypertriglyceridemia: 150 mg/dL (1.69 mmol/L)n Low high-density lipoprotein (HDL) cholesterol: < 40 mg/dL

(1.04 mmol/L) in men; < 50 mg/dL (1.29 mmol/L) in womenn High blood pressure: 130/85 mm Hgn High fasting glucose: 110 mg/dL (6.1 mmol/L)

7. Stay current in the latest advances in the diagnosis,prevention, and treatment of diabetes. This “will assistoral health professionals in providing better quality ofcare for people with diabetes.”20 One of the best sourcesfor this information is Diabetes Care.

8. Counsel obese patients about the possible oral compli-cations of obesity. Dental hygienists are uniquely posi-tioned to screen and counsel obese patients regardingthe influence of obesity on oral and systemic health. Itshould be mentioned that this type of therapeutic in-tervention is particularly relevant in younger popu-lations. “With obesity increasingly affecting youngpeople, the onset of type 2 diabetes is also shifting toyounger ages, leading to the earlier appearance of dia-betic complications.”43

9. Screen patients for MetS. In caring for patients whopresent with medical histories and physical signs in-dicating possible metabolic disorder, dental practi-tioners should ask the patient whether he or she hasbeen evaluated for MetS or its component risk factors(Table 3).44

10. For patients with diabetes, take the lead in developingtreatment plans that integrate strategies for risk reduc-tion such as smoking cessation and promotion of ahealthy lifestyle, such as advising about the ABCs ofdiabetes care: Attention to Hb A1c, Blood pressure,and Cholesterol.

11. For patients with diabetes and diseases of hard andsoft tissue of the oral cavity, inform the treating physi-cian of a patient with diabetes of the dental diagnosis,treatment plan, and any concerns about the patient’sability to undergo treatment, such as the potentialimpact of long and/or complicated dental procedures.A template for this type of dentist-to-physician com-munication can be developed. Research related to therelationship between diabetes and periodontal dis-ease is published in a number of highly reputable med-ical journals. Attaching copies of the original researchto the communication is an effective way to educatephysicians and other healthcare providers on the bidi-rectional relationship between diabetes and periodon-tal disease.

12. Train nondental care providers to screen for signs andsymptoms associated with periodontal disease, andprovide an expedient way to refer patients when peri-odontal disease is suspected. Nondental care providers

can screen for signs and symptoms associated with peri-odontal disease based on patient history, symptoms,and/or visual assessment of the patient’s teeth and gums.Nondental providers can reinforce the importance oforal health by recommending biannual dental exam-inations for those with diabetes or at risk for diabetes,in addition to encouraging strict compliance to patientself care/oral hygiene.

CONCLUSIONRecognition of the mounting evidence of relationshipsbetween oral and systemic health will confront dentalhygienists, dentists, physicians, nurses, and other health-care providers to the importance of working together. No-where is this more important than in the early identi-fication of individuals with undiagnosed diabetes and theco-management of the oral and overall health of patientswith diabetes.

There is sufficient evidence of a bidirectional relation-ship between diabetes and periodontal disease to formulateguidelines for screening for undiagnosed diabetes and theco-management of patients with diabetes in the clinicalpractice of dentistry and dental hygiene. There also existssufficient evidence on the role periodontal disease plays inincreasing systemic inflammation to suggest that nonden-tal care providers should screen patients for periodontaldisease. For those dental and nondental practitioners whoembrace the opportunity to become more actively involvedin this important arena of healthcare, this new and excitinglevel of clinical practice is certain to benefit patients and beprofessionally rewarding.

ABOUT THE AUTHORCasey Hein, BSDH, MBA, is the Director for Interprofes-sional Oral-Systemic Curriculum Development; AssistantClinical Professor in the Department of Periodontics, theUniversity of Manitoba, in Winnipeg, Canada. In this posi-tion, Hein is developing the first curriculum specificallyrelated to oral-systemic relationships for medical, nursing,pharmacy and dietitian students. She also has a joint ap-pointment at the University of Colorado School Of DentalMedicine as an assistant professor in Craniofacial Biologyand associate professor in Dental Hygiene. Hein’s passion isin translating credible findings of oral-systemic research andshe frequently speaks and writes on the topic. Casey can becontacted at [email protected].


Hein

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